Adult Psych Disorders (Factitious Disorder to Inpt. Txt)

factitious disorder (Munchausen’s Syndrome)

E: no quality studies
most knowledge case reports and speculation
developmental/maladaptive response to life events
potential “addiction”: done for personal gain
strong overlap with personality disorders

DX:
DSMV:
deception (false physical/psychological symptoms)
single/recurrent episodes

Goals of Care:
find evidence of pt. deception

tx: psycotherapy:
controntation:
need plan
multidisciplinary (nurse/PA/doctors/counselors/etc.)
most pts. deny care

Functional Neurologic Symptom Disorder (Conversion)

E: 4-12/100,000 per year
females
psychodynamic model: internal emotional conflict → repressed memory → physcial sx
CBT model: patient views/gets information about symptom→conversion based on fear of getting it→overrides sensory input → actual symptom

CM: signs of neurological/organical disease sx
inconsistencies on exam and symptoms
pt. indifference to condition

DX: altered voluntary sensory/motor function
evidence of symptom with no condition
symptom causes distress/impairment

TX: strong therapeutic alliance
pt. edu:
focus on symptoms being real
give examples of conversion symptoms
emphasize acceptance of disorder
1st line:
CBT
PT
2nd line: SSRI
SNRI

Premenstrual Syndrome

E:
47.8% of reproductive age women
20% dishabilitating symptoms

DX:
mood swings
irritability/anger
depressed mood
physical sx (breast tenderness/swelling, joint/muscle pain, bloating/weight gain)

TX:
NP: lifestyle changes (exercise, massage, light therapy)
P:
NSAIDS
SSRI
Oral contraceptives
GnRH agonists

premenstrual dysmorphic disorder

PP: severe PMS
E: 2% (lower than PMS)
CM: menstrual cycles interfere with daily life
TX: more aggressive PMS txt

Suicidal ideation

E: every 16.6 minutes=suicide
self-referral/brought in by someone/EMS

DX:assessment of: predisposing factors/risk factors/protective factors
scale for suicide ideation

TX: inpt.
NP: empathic safety
safety contract
ECT

P: SSRI/SNRI
Lithium (unipolar/bipolar)
Clozaril (schizophrenia)
Ketamine

Spectrum:
passive → active → planning → intent

DX:
Overtly suicidal:
listen empathetically
don’t rush to respond
look for risk factors
assess safety

covertly suicidal:
ask pt. future plans
question about killing themself
discuss concerns
plan next steps

protective factors:
behavioral healthcare
connection to others
life skills
self-esteem
sense of purpose
personal beliefs

Self Harm:
non-suicidal=grounding technique

Grounding techniques (Tx):
rubber band
ice
red paint
sensory box

personality disorder

PP:a way of thinking/feeling/behaving that deviates from the expectations of the culture
causes clinical distress/problems functioning
lasts over time

E: over 18 (under 18=personality developing)
9% US adults
childhood trauma/abuse/neglect

DX: can be dx with more than one type
at least 2
way of:
thinking about oneself/others
responding emotionally
relating to other people
controlling one’s behavior

delusional thinking or hallucinations
mood shifts: hours/days (not weeks/months)

Cluster A: Paranoid personality disorder

PP: distrust in others’ beliefs as being malevolent

E: early adult hood

DX:
DSM V:
4+ needed:
worries of deception/backstabbing from others
preoccupied with worries of others’ trustworthiness
reluctant to open up to others
finds backhanded comments when there are none
bears grudges
perceives attacks on character that aren’t apparent and quick to react in anger
irrational suspicions

PEARLS:
straightforward language to build trustSchio
don’t be overly friendly=draws skepticism

Cluster A: schizoid personality disorder

PP:detachment from social relationships with restricted range of expression of emotions when they are in interpersonal settings

E: prevalence less than 1%
heritability=30%
no environmental factors
early adulthood

Dx:
DSM V
4+ needed
neither desires nor enjoys close relationships
chooses solitary activities
no/little interest in sex
lacks close friends/confidants
indifferent to praise/criticism
emotional coldness/detachment/flattened affectivity

PEARLS:
don’t desire relationships
aren’t shy/socially anxious
straighforward Q&A effective

Cluster A: Schizotypal personality disorder

PP: discomfort and reduced capacity to have close relationships
eccentric behavior

DX:
DSM V
5+ needed
ideas of reference
strange beliefs/magical influence
abnormal perceptual experiences
strange thinking and speech
suspiciousness/paranormal ideation
inappropriate or constricted affect
strange behavior or appearance
lack of close friends
excessive social anxiety

PEARLS:
desires relationships but cant keep them
transient psychosis

Cluster B: antisocial personality disorder

PP: pervasive pattern of disregard for/violation of the rights of others

E: 1-4%
male 3-5x prevalence
genetics: 2p12 region on chromosome 2
disorder symptoms before age 15
diagnosed over 18

DX:
DSM V
3+ needed:
failure to conform to social norms/laws
deceitfulness, repeated lying, use of aliases, conning others
impulsivity/failure to plan
irritability and aggressiveness with fights and assaults
reckless disregard for safety of others
consistent irresponsibility, failure of work behavior, no honor
lack of remorse, no problem hurting/stealing others

TXT: none
no hospitalization (no effect)
can disrupt others in hospital

Cluster B: Borderline personality disorder

E: 1.6% gen pop
20% inpt. psych
genetics: twins=50% heritability
social factors: childhood maltreatment 70%
comorbid conditions (mood/anxiety/substance abuse/etc.)

DX:
avoid real/imagined abandonment
unstable and intense interpersonal relationships
persistently unstable self-image or sense of self
persistently unstable self-image/sense of self
impulsivity in at least 2 areas (sex/spending/substance abuse/reckless abuse/binge eating/etc.)
marked reactivity in mood
feelings of emptiness
inapropriate/intense anger
transient paranoid ideation or severe dissociative symptoms

PEARLS:
therapeutic relationship with provider=stability
set clear limits
watch out polypharmacy

P: 35% remission after 2 years
91% remission after 10 years
9% remission after 16 years

Cluster B: histrionic personality disorder

E: 2-3%
women (4x)
potential genetics
social factors: dramatic/erratic/volatile/inappropriate sexual behavior/children at risk
ego-syntonic: consider behavior normal and struggle to identify a problem

DX:
DSM V
5+ needed
uncomfortable when not the center of attention
seductive or provocative behavior
shifting. and shallow emotions
uses appearance to draw attention
impressionistic and vague speech
dramatic/exaggerated emotions
suggestive/gullible
considers relationship more intimate

Cluster B: Narcissistic personality disorder

E: 0.5-5% of US pop
possible genetic
social factor: neglect/excessive praise in childhood

DX:
DSM V
5+ needed
grandiose sense of self-importance
preoccupied with fantasies of success, power, brilliance, beauty, or perfect love
believes they’re special
requires excessive admiration
sense of entitlement
exploitative.takes adveantage
lacks empathy
envious of others
arrogant/haughty

PEARLS:
may be resistant to seeing PA
death is ultimate ego injury
dictator triad:
narcissist
paranoid
antisocial

Cluster C: avoidant personality disorder

E: early adulthood

DX: social inhibition
feelings of inadequacy
hypersensitivity to negative evaluation
DSM V:
4+ needed of following
avoids occupational activities that have interpersonal contact
unwilling to get involved with epople unless know they’ll. beliked
shows restraint with intimate relationships because of fear of being shamed/ridiculed
preoccupied with being criticized/rejected in social situations
inhibited in new interpersonal situations
poor self-image
unusually reluctant to take personal risks/engage in new activities

PEARLS:
be aware of desire not to challenge/be protective to patients
feel lonely
desire friendships

Cluster C: dependent personality disorder

E: early adulthood

DX: pervasive and excessive need to be taken care of
submissive and clinging behavior
fears of separation

DSMV:
5+ needed
has difficulty making decisions
needs others to assume responsibility
difficulty expressing disagreement
difficulty initiating things without others
excessively trying to get nurturance and support from others
uncomfortable or helpless when alone
urgently seeks another relationship
fears of being left to take care of themselves

cluster C: obsessive compulsive personality disorder

E: early adulthood
2.1-7.9%
higher in healthcare providers

DX: preoccupation with orderliness/perfectionism/mental and interpersonal control at expense of flexibility/openness/efficiency

DSM V:
4+ needed
preoccupied with lists/details/schedules/organization
shows perfectionism that interferes with completion of task
excessively devoted to work and productivity and ignores leisure activities
strict on morals/ethics/values
doesn’t want others to do task
hoards money
rigidity
stubbornness

treatment of personality disorders

gold standard: dialectic behavioral therapy
treat comorbidities (anxiety/depression/psychotic disorder) with antidepressants/mood stabilizers/antipsychotics
fish oil can help stabilize mood

Do not miss:
physical causes for mood fluctuation/psychosis
treatable mental health conditions
abuse/neglect
substance abuse

recognize transference/countertransference
set clear boundaries
treat using evidence-based medicine

BPD: don’t use insulin/use too much=manipulation
OCPD: vague terminology
paranoid personality: overly friendly approach

Transference

pt transfers emotions on to provider
barrier to continued progress

countertransferrence

provider transfers emotions to patient
can serve as diagnostic tool

cognitive behavioral therapy

best/most researched style of psychotherapy
Aaron beck
Uses APA core principles:
psycholoigcal problems are based on faulty/unhelpful ways of thinking
psychological problems are based on learned patterns of unhelpful behavior
pts can learn better ways of coping thus making them better

recognize thought distortions
better understanding the behavior and thinking of others
gaining problem solving skills
enhancing one’s confidence in their own abilities

Electroconvulsive therapy

TI: resistant depression/severe major depression/suicidal ideation/severe psychosis/catatonia

suicidal ideation cure:
1 week: 31%
2 weeks: 61%
after completion: 81%

CI:
Absolute:
pheochromocytoma
elevated intracranial pressure WITH mass effect

relative:
elevated intracranial pressure WITHOUT mass effect
CV conduction defefcts
high risk pregnancies
aortic/cerebral aneurysms

Procedure:
pt. taken to suite
blood pressure cuff half inflation/EMG placed on foot to record/visualize seizure activity
bite block placed in pt mouth
electrodes placed on temples and shock administered
seizure for 15-70 seconds
pt woken up and taken to recovery

Inpatient treatment admission

voluntary (201):
patient and provider agree
pt. signs document
locked. in for 72 hrs
can be converted to 302

involuntary (302):
pt. doesn’t agree
petitioner requests evaluation by mental health provider/pt. shows clear and present dangers to others/self
302: 5 days until brought to mental health court
303: 20 days
304b: 90 days
305: 180 days